WEIGHT-LOSS SURGERY AND TRANSFORMATION, CONTINUED

On May 2, 2016, the New York Times made a bit of a furor when it published an article called “After ‘The Biggest Loser,’ Their Bodies Fought to Regain the Weight.” The majority of contestants were gaining weight back – not surprising to most readers. What did seem to surprise people was why. These contestants were under extreme scrutiny; they’d been tested every which way before, during, and now after weight loss; and clearly weight loss had changed their bodies. If you read the article, you’ll see helpful statistics next to each person’s picture: “Now burns 800 fewer calories a day than would be expected for a man his size.” Hormone levels had changed as well.

Why this surprised anybody is a mystery to me, because we’ve known this for a long time. According to the American Society for Metabolic and Bariatric Surgery, “Individuals affected by severe obesity are resistant to long-term weight-loss by diet and exercise… There are significant biological differences between someone who has lost weight by diet and someone of the same size and body composition to that of an individual who has never lost weight.”

Clinicians see it as well. One of the responses to the article, from a Connecticut doctor:

“I am an M.D. who works with patients to optimize weight loss every day and I teach at Columbia. Eighty percent of my practice is metabolic related. For example, I saw a 20-year-old student about two hours ago who is barely eating (800-1000 calories per day) and exercising for an hour per day (mostly aerobic) just to maintain her mildly overweight build in the face of pre-diabetes. Her body fights her for EVERY pound, EVERY day, ceaselessly. This article is exactly what I see in daily clinically practice — how losing weight is the relatively easy part compared to the chronic battle one has as the body relentlessly tries to return you to the ‘set’ weight it wants.”

But the myth (body reflects character) has been just too strong to dislodge. I’m not going to summarize here all the scientific literature of the last thirty years. I’m simply going to list a few things that suggest the world is not what most people think it is.

Let’s begin with one: antibiotics. We know they make pigs and cattle fat, which is why they’re controversially fed in bulk to those animals destined for slaughter. But wait, how is this even possible if fatness is about the state of your soul? Chemicals in your body actually make a difference? Surely those animals are just weak-willed and need a good talking-to. Nonetheless, scientists are now examining the more-than-possibility that antibiotics are, statistically, helping to make primates like us fatter too.

Antibiotics change the ecology of your gut microbes. So let’s talk about those critters for a moment.

“In 2013, researchers in Jeffrey Gordon’s lab at Washington University tracked down pairs of twins of whom one was obese and one lean. He took gut microbes from each, and inserted them into the intestines of microbe-free mice. Mice that got microbes from an obese twin gained weight; the others remained lean, despite eating the exact same diet.” (http://www.theatlantic.com/health/archive/2016/01/what-does-a-calorie-measure/427089/)

Those damned mice and their lack of discipline! Somehow the weak-willed ones must have all ended up in the transplanted-microbes side of the study.

It’s known now that obese microbiota are different from healthy microbiota. Here’s another quick reference link — just to a Times video, but you can follow it back further if you like.

Same food; different outcomes. This simple fact by itself pretty much explodes “calories in, calories out” and “I’m skinnier than you because my heart is pure.”

Some people like to simplify everything, so those most drawn to believing their sterling character makes them slender will quickly re-interpret anything I write here to “so you’re saying it makes no difference what fat people eat, huh?”

No, I’m not. I am, antithetically to all Internet communication, suggesting that there is a spectrum here, a continuum. Nuance. That everyone is not the same blank slate; that some of our slates, in fact, are pretty banged up.

The inspiration was an experiment in the 1950s, in which inmates at the Vermont State Prison were offered a chance at early release if they would participate in a study that required them to gain 25 percent more of their current body weight. The idea was to track hormonal changes in the newly obese, and for that, they needed newly obese subjects. The study showed some of the first cracks in our primitive understanding of weight gain; the people running it became concerned when some of the prisoners simply proved incapable of gaining the weight they were supposed to, no matter how much they ate. It was an intriguing anomaly; and if it was true that some people just don’t become overweight, regardless of intake… how does that mechanism work?

The more recent experiment the documentary focused on used ordinary people to recapitulate this study in a less dangerous way, in the hope of understanding the phenomenon. Subjects who had been thin all their lives were asked to eat twice their normal number of calories and avoid physical activity. This was controversial because even those who deny it sort of understand that there is something different going on in the bodies of fat people, and that this might push those subjects over the line permanently — which is asking rather a lot for the sake of science. The hope was that by limiting the study time to a month, the body’s setpoint would not have time to recalibrate. If, within that time, anyone gained 15 percent of their body weight, they’d be kicked off the project and encouraged to return to their baseline.

If everyone is alike, and all bodies are alike, and fatness is only a matter of lack of discipline, we might assume that the subjects rejoiced in knowing they could slip the reins and eat as much as they pleased. Unfortunately for them… they were already eating as much as they pleased. And when they were shown the amount of food they’d have to eat per day — about 5,000 calories for men — their hearts sank and they started to realize this was going to be tough.

And it was. The short and dirty version is this: our body’s hormones have ways of keeping you at your setpoint. One way is this: when you try to eat too far above your setpoint, food begins to look greasy and sickening and unappealing. You can do it for a while — pigging out at Thanksgiving, for example — but every day? It’s stomach-turning, and people don’t understand how awful it is till they try. The subjects found it hard, repulsive work — so hard, they couldn’t quite manage to eat what they were supposed to. So one by one they turned to the magic bullet: densely caloric chocolate.

A few of the subjects just never did gain weight. Most of them managed to gain some, but they were fighting their body’s inclinations all the way. And the second they were released from their obligations, they zoomed back down to their normal setpoint.

The study group was small, but it suggests that while a few people may be able to eat huge amounts and never gain, for the majority of the slender, their bodies are simply regulated to find too much over-eating sickening. It wasn’t iron will and sterling character that had kept them slim all their lives; it was natural to them to be as they were, and changing that required a daily, hourly, unpleasant struggle with their bodies. They were glad when that struggle ended. (Interestingly, they were not consciously aware of any of this before the experiment began; one man made the old joke about being on a seafood diet — “I see food, I eat it.” But not so; he followed the guidance of his hormones.)

It makes sense then, that for people who have been obese most of their lives, their hormones will work to keep them from getting too far below their setpoint. Lose 10 pounds, take in fewer calories per day, and heavens, that plate of french fries suddenly looks sublime. You become faint with longing, but turn away… and then it calls to you obsessively, like a relentless pop-up, when you’re trying to work.

And your setpoint can always change for the worse. Drs. A Lusis and Brian Parks at UCLA did it to their lab mice. The doctors fed them “junk-food pellets,” then tracked the bacterial composition of their guts. “What we found was that the composition of the gut shifted from bacteria that seem to inhibit fat gain to types of bacteria suspected to increase fat gain. And they did this in different degrees, depending on the strain.”

I know just when my own setpoint changed. It was at about age 6, around 1961. Before that, I was a slender little girl; afterward, I was never slender again – or not till 2015, at age 59, after weight-loss surgery.

“Think of the starving children in Europe.” My mother had internalized, after the war, the fact that times were tough across the ocean. She did not let go of this fact for decades. It was unclear to me, even at the age of five or six, what cleaning my plate would do to help the starving children in Europe, but it seemed important to my mother. I ignored her pleas for a long time, but finally, one night, decided to make an extra effort and finish all my hamburger. I was physically uncomfortable doing it, but I did feel a sense of accomplishment. Once I’d learned I could succeed at this project, I went on doing it. (To this day, in fact, it takes effort and attention to leave food on my plate, so I don’t put much on to begin with.)

This new eating-past-the-point-of-comfort way of life coincided with first grade and learning to read. Suddenly I was ingesting more calories and sitting still with books. It was a fatal combination. Soon enough, my body adjusted and I no longer had to force myself to finish everything — I wanted to finish everything. Food became more attractive. (Of course, if my mother had known what sort of life my new over-eating project would let me in for, she never would have nagged me. She hated having a fat daughter.)

Tl, dr: Once you’ve been obese for a substantial period of time, the rules you live with are different.

When you diet you work at it. It requires a huge amount of focus and energy. You are going against the tide, and while anyone can do that for a short period of time, just as most people can stand up for a short period of time — keeping it going becomes tougher and tougher. This is difficult to explain to those who say, “Making someone stand up for a prolonged period is torture? Ridiculous! I stand up all the time!” Or “Hey, fat person, you just need to have a strong character with a will of steel! Like me.” I’m always impressed at how some people are so beforehand in attributing everything to their own wonderfulness. They’re like investors whose portfolios go up when the entire market is going up, and think they’re stock-picking geniuses.

PART 3: THE IRON LAWS THAT RULE YOU

Here’s a metaphor: dieting, for the morbidly obese, is like walking across the United States. You’ve got, say, 130 pounds to lose: so start metaphorically walking. LA to Virginia Beach. That’s pretty much how much energy and focus it takes; it demands everything from you, and it goes on forever. In the sun, in the rain, with blisters, slowly. Very slowly. Get on that scale and hope you won’t be disillusioned.

Because your focus and attention are often broken by the universe blowing a big raspberry at you. That is, you work and work and work and work, fighting that pop-up balloon of temptation throughout the day, every day, and yet because weight fluctuates — and as noted, your body’s weight thermostat is trying to keep you from losing — it is entirely possible that sometimes you will get on the scale and discover you gained a pound this week. How is this even possible? It’s as if, on your walk across the US, you made it to Ohio and found yourself waking up the next morning back in Utah. “I was in Utah last week!” Yeah, sorry about that, but thanks for playing. Now start walking those same miles over again…

When at last you crawl into Virginia Beach you fall down on the bed at a cheap motel and slip into a stupor. Finally, finally, rest. Of course… you only lost 50 pounds. What about the remaining 70? Yeah, those pounds are gonna have to wait. You can’t just stroll chipperly out your door tomorrow morning and start walking back across the freaking United States. That’s going to have to wait till you’re stronger. Maybe in a few months, a year. Two years. Because if you’ve never been there, you’ll just have to take my word for how drained you are at this point.

Of course, by the time you feel ready to tackle it again you’ll have gained all that weight back, and maybe more, so…

This is how it works. It is not like the eight pounds Lily Ann lost to fit into her new bathing suit. It is a fucking slog that people who have never done it — or done it, say, three or four or seven times over the course of decades — cannot fully comprehend.

It’s a small world in the television business, and people gossip. One day the executive producer of a show I was on commented on a certain famous executive producer whose pilot was just picked up; that EP was morbidly obese. My EP had been talking with his wife, and they’d both thought this might be the perfect time for Fat Showrunner to diet. They didn’t say this in a judgmental way; they simply thought, from their distant seats in the upper mezzanine, he’d be too busy getting this new series up to indulge in food. So they assumed it would be a great strategic time to go for it.

I, Fat Writer, did not comment, but internally I was shaking my head. I knew that plan would never work. Because when someone morbidly obese sets out on a massive diet, they must hand their brain over to that project.

Here’s how the hormonally driven pop-up in your brain works, while you’re trying to work:

“How can I reconcile those two scenes (FRENCH FRIES!) — shit, okay, those two scenes, when we have to let the audience know ahead of time that (FRENCH FRIES!) — shit, no, no French fries, I can have skinless chicken in an hour, no French fries, I’m good, right, where was I? (HUNGRY HUNGRY RUMBLE REFRIGERATOR)…” And then there’s the planning of meals, and the considering of meals, and the energy to convince yourself the meals are adequate… and the obsessive, time-consuming cutting up of vegetables and the like, unless you can pay someone to do that for you. And the constant knowledge that you’re doing your best to exist on what feels like dust and cut grass.

No. Don’t try this when you’re entering into an all-consuming new job.

This is why the vast majority of fat people can lose weight for a while, but just can’t continue that focus and intensity for the rest of their lives. Now, interestingly, there are a very, very few who do just that. I read long ago that such people tend to make weight loss a career, founding or working for companies that encourage people to slenderize. And I understood why, as soon as I read that. Because they’ve turned their brains over to the grim fight, forevermore. They’ve made it their life’s work. Like saints who’ve founded a monastery.

I once read an article in the NY Times about a couple who’d lost significant weight together. The journalist writing the article followed them around as they rode their bikes and ate their diet food; they’d maintained their loss for quite a while. And for a moment I dared to hope. I thought, “Maybe it doesn’t have to turn you into a grim, obsessed person!” And then I got to the point in the article where the writer actually described the couple with the word “grim.”

All this is what brought me to a conclusion you may find controversial. I don’t believe that, if a person has been significantly obese for years, they will ever be able to lose that weight on their own and keep it off — with those rare exceptions who grimly make weight their life’s focus.

I’m a writer. That’s what I’ve handed my brain over to. When I’m in the middle of a project, I wake up in the middle of the night thinking about scenes and possibilities. I brush my teeth thinking about scenes and possibilities. I didn’t want to hand my brain over to a continual struggle against my body; I didn’t want to make that my life’s work, tied to the mundane with hoops of steel, running forever just to stay in the same place. Not creating anything any more, because you really have to hand your brain over to writing, if you’re going to write well.

I thought, well, maybe I just have to accept remaining fat all my life, cutting 10-15 years off my span, as the price of being a good writer and a whole person.

PART FOUR: WHAT PLAGUE-RIDDEN LONDON AND FAT PEOPLE HAVE IN COMMON

In Daniel Defoe’s Journal of the Plague Year, he talks about what happened in London when the plague first struck. As the contagion spread, gatherings of more than three or four people were forbidden; houses were quarantined; people feared their neighbors. But as that horrible year wore on and the death levels rose and rose and rose again, eventually attitudes changed. People stopped thinking they could out-think and out-run the plague. If they felt like it, they partied like it was 1699, in gatherings as large as they pleased – because if God was going to strike them down, He would. They were powerless to affect what would happen. No point in pretending.

Fatalism and fat; they go together. So when you are sitting beside a fat person at a celebratory dinner and they finish it up with chocolate cake, feel free to look at them and think, “Foolish! They’ll never be a slender person that way.” Could they hear your thought, they’d roll their eyes at you and say, “Right, because there’s any way at all I’ll be a slender person.” Back when I was young and still believed in dieting, I’d think maybe, someday, some year, when I had the endurance, somehow I might be slender; but if you believe this, give it a few decades. You’ll also figure, hell, I’m dying early but at least I’ll get a piece of cake tonight. Not a fair trade but it’s all I’ve got.

Basically, I’d been seriously obese for virtually all my life and I’d come to consider any change an impossibility. I’d speculate sometimes how much we (my fat brethren and I) would be willing to pay, if we could magically improve our lot. If a genie demanded money for snapping his fingers and offering a “normal” body — a life without the constant burden of physical effort, shortness of breath, high blood pressure, heart issues. And the constant social effort that anyone in any way “different” must exert, even on an unconscious level, to help the people around them forget that difference.

Sixty thousand dollars? Two hundred thousand? People buy houses for three or four hundred thousand — how many of those in my outcast tribe would give up their home and rent cheap apartments forever, if it would lift this burden from their shoulders?

And now let me stop here and say something important. Don’t misunderstand me. I’m not saying that being fat casts a shadow over all of life’s pleasures, or that you can’t be proud of who you are, poundage and all. But this isn’t an essay about the delights of my garden or the consolations of art and love and friendship. I could talk about those for hours.

This is simply about whether it’s possible to extricate yourself from the trap of morbid obesity.

I started to wonder, over the years. Scientific reading aside, I had my own experience to go by, and as far back as 15-20 years ago I found myself thinking, “Diet and exercise are supposed to be the answer. Yet practically nobody loses weight and keeps it off! Surely we–” (and by “we” I meant “I”) “–need a new plan. When something’s broken you can’t keep hauling it out for another try as though this time things will be different.” I wasn’t sure what the new plan might be. Surgery? Weight-loss pills? Some damn thing was needed. So I went to see my primary doctor about it.

He said, more or less, that I didn’t need pills or surgery. I just needed to start walking across the United States again…

In retrospect, I feel as though I wasted at least 10 years of potentially healthful living through that conversation.

PART FIVE: SURGERY

About six years ago, some frightening symptoms led me to a cardiologist, who said, in the Serious Voice, that I needed to lose weight. I agreed. I was worried. Did I do it? No.

I had other chronic conditions that might be helped if I could lose weight. Did I do it? Of course not.

Action, dammit, needed to be taken. I was getting older, and I wanted a healthy retirement, if I couldn’t have an entire healthy life. I still had a lot of books to write. Was there no way to manage my recalcitrant metabolism? I’d read about gastric bypass surgery, but it frankly scared me – the malabsorption, the dumping syndrome, the percent of fatalities. A friend’s sister died of complications. But I knew I needed to do something. Perhaps that lap band procedure I’d heard about… ? Though the statistics on that were not as successful as I’d hoped, and the idea of having a foreign object around my stomach, possibly eroding into it, was disturbing.

But I needed to improve my health if I was going to have a shot at any length or quality of life. I mentioned to a business friend that I was thinking of doing something “drastic.” He told me I should talk with a friend of his who’d really done something drastic – weight-loss surgery. I said, “That’s exactly who I need to talk with.” I emailed her to ask about her lap band, and she replied, “I didn’t have lap-band surgery. I had gastric sleeve. It’s new, and less invasive than gastric bypass.”

So I had coffee with her. Basically, gastric sleeve reduces the size of your stomach. That’s all it does. There’s no removal of intestines, no addition of a band — also no dumping syndrome, no malabsorption. But, importantly, they try to remove the part of your stomach that secretes ghrelin. Ghrelin is one of the hormones your body uses to make you hungry every time you try to diet. It’s a nightstick in the hand of your tyrant setpoint.

I did a lot of research, and the surgeon’s office made me jump through a lot of hoops. I had to get sign-offs from my cardiologist, my gastroenterologist, and a psychologist. I had to lay out my dieting history over the past 40 years, something that took months over the brief intervals of time I could grab away from work. (And a couple of months after I handed it in, the surgeon’s office lost it.) And of course, I was working on the staff of a television show at the time, so I couldn’t take the time for surgery till hiatus, and by then I’d missed too many prep appointments. I had to wait another damned year.

Most doctors will support you when you tell them what you’re doing – some, like some friends, will look at you with big horrified eyes. “Surgery???” I call these the “can’t you just” people. Can’t you just eat less and exercise more? Can’t you just go to one of these fat boot camps? Because somehow that will change your life forever. It reminded me of when I was on a medical show, and I tried to convince my executive producer to let me write an episode about body dysmorphia. He didn’t think there’d be sufficient sympathy or suspense if I wrote about someone who wanted to, say, cut off a body part. Because you could just tell them, “Don’t do that.” I, then-50-year-old Fat Writer, argued, “You could say the same thing to someone who’s fat. Try eating less, exercising more.” He nodded, because of course that makes sense if you’ve never been down my road. I made the cartoon gesture of smacking my forehead with my open palm: “Why didn’t I think of that!”

My point, of course, was that it’s a wee bit more complex than that. I never did convince him to let me write about body dysmorphia. But when I delivered that line, one of the other writers burst into laughter. And that writer did go on to write a not-unsympathetic script about an 600-pound man who had to have the front of his house broken out in order to be removed to a hospital, so God bless him.

My hospital, which I highly recommend, was St. Joseph’s in Burbank. I showed up with a friend at 6 am, only to find the insurance arrangements had somehow gotten disarranged (not the fault of the hospital). At 6:30, as the surgical nurse called to ask where I was, the woman in Admitting was telling me those fatal words, “Your papers are not in order.” And because it was so early, they couldn’t call the main insurance office in Seattle for confirmation; no one would be there. But it was “probably” okay, so why not just go ahead and have the surgery? (Of course, if it turned out there was in fact a problem, I’d be on the hook for many thousands of dollars.)

Once I got past that, I was whisked up to surgery and prepared. The last thing I was given before anesthesia were papers to sign that said I agreed that if the surgeon decided to do something different once he opened me up, I approved it. Normally I would think this made sense – what if he found cancer or some other anomaly? But you could also interpret it as the surgeon deciding to do a gastric bypass – the much more invasive procedure – instead of the sleeve. I said this to the nurse, half-jokingly. The nurse simply nodded: “That’s what it means.”

Now, while I was staunchly against a gastric bypass for myself, I was not necessarily 100 percent against it. It was the sort of thing that, if a surgeon really wanted to do, I’d like to discuss the pros and cons in detail, in his office. And then go away and think about it, hard. Three minutes before anesthesia with only a pen and my best guess would not be my preferred strategy.

As they wheeled me away and the anesthesia took effect, the nurse leaned down and said encouragingly, “I told him you don’t want a bypass.” It was kindly meant, and I hoped for the best.

I woke up a couple of hours later – it’s a quick operation – with a stomach the size of a walnut. And excruciating back pain behind my shoulder blades. I passed one of the worst days of my life, moving awkwardly from one vain position to another, longing desperately for a heating pad or some other relief. On the other hand, my stomach felt fine, and has felt fine ever since; the operation was a success. But I’ve spent the last year and a half going to physical therapy for the back pain that surgery awakened. (I could say a lot more about this, but the focus of my writing here is the surgery’s effect on my weight.)

Aside from the back pain, and a super attack of acid reflux that sent me into full-body spasms, I was fine. (That, they could treat; it passed.) Everyone in the hospital was gentle and helpful. I was connected up to an IV and a drain, and took them with me as I made the circuit of the floor, dutifully inscribing another mark in my exercise chart each time I did. I drank as much of the liquid protein meal as I could get down. Late that first evening, a friend came by with a heating pad. My window looked north, and a gray evening faded into night.

I curled up on the bed, on my right side, so the drain remained in, and fell asleep. Around midnight I heard the weather change; gusts of wind, and the sound of a downpour.